Current practices and trends in surgical decision-making for children withLennox-Gastaut syndrome: A cross-sectional survey by the Pediatric EpilepsyResearch Consortium
Epilepsia Open Volume 10 Issue 6
AUTHORS
Michelle Y Chiu 1, Cynthia G Keator 2, Aaron E L Warren 3, Juliet K Knowles 4, Debopam Samanta 5, Tracy Dixon-Salazar 6, Hyun Yong Koh 7, Syndi A Seinfeld 8, Juliann Paolicchi 9, Jorge Vidaurre 10, Anup D Patel 10, Tobias Loddenkemper 1, Renée A Shellhaas 11, Dave F Clarke 12, Anthony L Fine 13, Sonam Bhalla 14, Dewi Depositario-Cabacar 15, Babitha Haridas 16, Carl E Stafstrom 16, Gozde Erdemir 17, Cemal Karakas 18
ABSTRACT
Objective: The objective of this study is to characterize contemporary surgical management practices and factors influencing surgical decision-making in the management of Lennox-Gastaut Syndrome (LGS) across pediatric epilepsy centers in the United States.
Methods: A 45-item cross-sectional survey was developed and distributed to Pediatric Epilepsy Research Consortium centers. Domains included institutional demographics, surgical evaluation timing and goals, presurgical workup, procedural utilization and outcomes, and barriers to surgery. Descriptive statistics and thematic analysis were performed.
Results: Thirty-two pediatric epilepsy centers participated (38% response), the majority comprising pediatric epileptologists at Level 4 National Association of Epilepsy Centers. Most centers (66%) considered surgery after failure of 3-4 antiseizure medications. Presurgical workup typically included brain magnetic resonance imaging (MRI), long-term electroencephalography (EEG) monitoring, and neuropsychological assessment, while use of functional imaging, magnetoencephalography, and intracranial EEG varied considerably. All centers offered vagus nerve stimulation and corpus callosotomy; 80%-90% offered resection, hemispherectomy, responsive neurostimulation (RNS); 60%-65% offered deep brain stimulation (DBS) and laser ablation. Among centers offering RNS, half targeted thalamic structures exclusively, and the remainder targeted cortical or combined cortical-thalamic structures; the centromedian nucleus was the preferred thalamic target for RNS and DBS. Surgical decision-making was influenced by patient characteristics, procedural considerations, and systemic factors. Seizure frequency, family preference, and multidisciplinary input were highly rated across all interventions. Etiology was critical for resection and hemispherectomy, while financial constraints, insurance barriers, and the need for future neuroimaging impacted neuromodulation selection. Scenario-specific trends included less frequent consideration of DBS and RNS in children under five years, less use of hemispherectomy in older children, preference for corpus callosotomy in children with predominantly drop seizures, and procedural selection based on MRI findings.
Significance: Substantial variability exists in the surgical management of LGS. These findings highlight critical opportunities to harmonize practices, reduce disparities, and guide comparative effectiveness research to optimize outcomes.
Plain language summary: Lennox-Gastaut Syndrome (LGS) is a severe form of epilepsy that may require surgery when medications are not effective. This study found that surgical care for LGS varies widely across pediatric epilepsy centers in the United States, including when surgery is recommended, how patients are evaluated, and which procedures are available. Newer approaches such as brain stimulation are being used more often, although access remains inconsistent. These findings highlight the need for clearer treatment pathways to ensure that children with LGS have equitable access to the best possible care.